Metabolic Workup for Bone Stress Injury: A Practical Approach for Evaluating Bone Health in Athletes.

CONTEXT: This review synthesizes current literature regarding metabolic aspects of athlete bone health and incorporates evidence-based recommendations into a clinician-friendly algorithm. EVIDENCE ACQUISITION: Published manuscripts listed in PubMed between 1993 and 2024 were reviewed. Relevant terms including keywords and section titles of manuscripts were searched, and relevant studies identified. STUDY DESIGN: Clinical review. LEVEL OF EVIDENCE: Level 1-3. RESULTS: A metabolic workup is often appropriate in the context of an athlete with bone stress injury (BSI) but varies based on clinical scenario. Evidence supports that all athletes with BSI be considered for a minimum workup including 25-hydroxyvitamin D (SORT A), complete blood count (CBC) (SORT B), and an iron panel with ferritin (SORT B). Athletes with features of low energy availability, including ≥2 Triad risk factors (low body mass index, abnormal uterine bleeding), or with multiple features of relative energy deficiency in sport require an initial strategy to correct energy availability (increased energy intake and/or decreased training load) and should be considered for dual-energy x-ray absorptiometry (DXA) (SORT A) and additional laboratory testing. If there is persistent clinical concern, a comprehensive laboratory evaluation should be considered, and varies based on athlete sex and clinical context. People with recurrent or multiple BSI or requiring surgical fixation also warrant detailed, stepwise testing for underlying causes (SORT C). A reasonable strategy starts with a focused workup for more common conditions (eg, CBC, complete metabolic panel, iron panel, 25-OH vitamin D, DXA) and may expand based on initial findings and clinical suspicion. CONCLUSION: Existing evidence supports optimizing nutrition and further evaluation for factors influencing bone health for all athletes with BSI. More extensive workup is required in athletes with multiple features of low energy availability, multiple/recurrent BSI, BSI requiring surgical fixation, and signs/symptoms of an underlying medical disorder.Strength-of-Recommendation Taxonomy (SORT):A, B, C.